Category Archives: Professionalism

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I take care of non-conforming teens, but I have many colleagues who are “uncomfortable” with what they call the “new” issues of sexuality. I am convinced it’s because they don’t know the science, the vocabulary and how to speak to non-conforming teens.

This presentation was put together for my pediatric surgery colleagues as a project for a course I’m taking, but several of them asked me to make it more available so they could share it, which is why I’m posting it here.

Research has demonstrated that most aspects of sexuality are far from binary (either-or). We now understand that sex, gender, identity, expression and attraction are separate aspects of sexuality – and that they can be quite varied and fluid (i.e. can differ over time or in different situations).

Pediatric surgeons are among the professionals who care for babies who are born with ambiguous genitalia or, more correctly, what is known as “disorders of sexual development“. For pediatric surgeons, it’s been clear for a very long time that there are three categories for “sex” – male, female and intersex. Almost 2% of children are intersex (which, by the way is the same percentage as the number of people who have red hair).

Gender refers to the identity we hold as an individual. I love this particular diagram with “Barbie” on the left and “GI Joe” on the right. What a delight that we have people all along this spectrum! It’s also true that there may be days you are a 5 and other days your are an 8… whether your sex is male, female or intersex.

Because it’s such a spectrum, there are different ways to describe someone’s identity. This chart represents the most common words used. Cis-gender may or may not be familiar to you, because it is the correct way to describe what is usually (but sometimes not correctly) assumed – i.e. that a person’s gender is the same as their sex.

When we have patients, friends or colleagues who are non-conforming, it is our responsibility to address them in a way that affirms them as human beings. For those who have a clear gender identity (whether its cis-gender or transgender) it is fairly straight forward. When addressing non-binary folks, the correct pronouns to use are they/them/theirs. This is hard for most people because it’s new. It’s perfectly ok to tell them it’s hard but that you are going to try your best. The other important take home message is that if you aren’t sure, it’s ok to ask.

To add even more to the amazing diversity of human beings, how you express your gender is also completely separate from your sex and your gender identity! So, you can be born with female genitalia (sex = female), identify as a girl (cis-gender) but still choose a gender expression that is more typically “male” in terms of behavior and dress. Gender expression is also amazingly fluid, since there are other times this same individual may prefer to express as “Barbie”, somewhere in the middle, or “GI Joe”.

Although most people are familiar with bisexual, homosexual and heterosexual as concepts, the fact that there are people who are asexual may be a new concept to many.

The Genderbread person is a wonderful visual representation that sex, gender, expression and attraction can all be independent of each other.

So what prompted this presentation and now this blog post? Gender dysphoria is real, although not common, and it is a state of suffering. There is so much stigma in our society around sexuality that these children and young adults feel ostracized and isolated. As professionals who care for children and young adults, it is important that we understand these issues, learn to speak openly with patients and families experiencing the effects of gender dysphoria and refer them for appropriate medical and psychological care.

It’s hard to know what to say, but it’s so important to say it. Being open – even admitting that you don’t know much about sexual fluidity – is key. More importantly, caring enough to ask and learn may save a life.

BTW – if you are teen reading this and I’ve messed up, please contact me!

I teach embryology to wonderful first year medical, nurse anesthetist and PA students. Last week, one of my students asked me, humbly and thoughtfully, if (and when) a fetus feels pain. Because of recent publicity concerning late term abortions, I knew this was a question about more than fetal physiology.

As healers, we seek to relieve suffering. Let’s be clear – that’s not the same thing as the “pain” I mentioned above. Let me give you a couple of (real life) examples.

A developmentally delayed 15 year old is raped by her cousin who threatens her if she tells anyone. Over the next two months, the girl becomes progressively withdrawn, depressed and even suicidal. Her mother takes her to her pediatrician who is able to convince the girl to tell her what happened. She sends the appropriate labs, including a pregnancy test, which is positive. Her pediatrician recommends termination of the pregnancy, and refers her to a gynecologist and a pediatric psychiatrist. Because of her depression and suicidality, both of these physicians also recommend termination of the now 14 week pregnancy.

A young couple comes to their gynecologist for a routine screening ultrasound. Something isn’t quite right, so they are sent to the maternal-fetal medicine clinic for a more detailed ultrasound. They are at 18 weeks gestation, which means 22 more weeks until term. They receive horrible news. The fetus they are carrying has a fatal disorder and will not survive after birth. After a few weeks, they return to their doctor in tears. The emotional burden of carrying the pregnancy to term is causing them immense suffering.

Let’s talk ethics.

We teach our medical students to take complex situations like deciding to terminate a pregnancy and use an “ethics workup” to help guide decision making. The ethics workup starts with defining everyone who might be affected by the decision. For example, in the first case I mentioned above, that would be the 15 year old patient, the fetus, the patient’s mother, and the doctors. Then, based on the possible outcomes (to terminate or not to terminate the pregnancy), we consider the outcomes with appeals to consequences, professional obligations, ethical rights and virtues. What this process does is allow us to understand the complexity of the situation and the choices being made, rather than just going with our “gut reaction”.

Let’s talk about listening.

When I was Dean of Student Affairs, the “Pro-Life” group on campus invited a speaker that the “Pro-Choice” group felt strongly should not be allowed to speak. I asked the leaders of both groups to meet with me. They were pre-clinical students who had not yet experienced dealing with patients and families facing complex and heartbreaking decisions. I recognized that their conflict was a great learning opportunity, a chance to learn to work through a situation where colleagues disagreed. I asked them to develop a plan together on how speakers should be invited, a plan that I insisted reflect the culture of tolerance at our medical school. They did not disappoint. Their plan was amazing and included attending each other’s meetings and reviewing speakers for each other before invitations were issued. They also wrote a beautiful statement to be read at the beginning of each meeting explaining that they were there to learn from each other and to listen. They went even further and added that disrespectful comments or intolerance would result in being asked to leave the meeting. What a great example for us all – to listen to learn, and to do so with kindness and tolerance.

As physicians we are absolutely allowed – even encouraged – to include our personal views when making a thoughtful, ethical decision about caring for a specific patient. Although it’s not a common event, physicians are allowed to choose not to care for a specific patient as long as they refer them to a different doctor. What physicians are not allowed to do is to impose our views on our patients, or our colleagues.

Being “board certified” means that one of the 24 specialty boards in the United States attests that you have met all the requirements and have passed rigorous exams to show that you are qualified to practice in that specialty.

Does the board certification last forever?

Short answer, no. Family Medicine was the first specialty (in 1970) to realize that initial certification was not enough. As the public continued to ask for evidence that physicians remained up to date, Surgery (1976), Emergency Medicine (1980) and Ob/Gyn (1986) added a recertification examination. As of 1990, the remaining boards became “time-limited” which means board certification expires after 6-10 years, unless physicians take and pass the recertification examination. So, many internists who are now in their 60s and 70s didn’t have to do anything other than pass the initial examinations. (This is referred to as being “grandfathered”).

Who makes up “the board” for the specialties?

The members of most boards are volunteer physicians in the specialty. In surgery, which I know the best, the board members are called “directors”. There are 41 directors of the American Board of Surgery who represent a variety of organizations and specialties in surgery. These volunteer surgeons spend 20+ days a year away from their practices with no pay (although their expenses are paid) to give the oral examinations in surgery, and to design and validate the written examinations. They also have a variety of committees and projects which focused on one critical question: “What do we need to do to make sure we maintain the public trust in surgeons?”

Since 1990, boards have to be “maintained”. If you don’t maintain your board, you lose it. Hence the term, Maintenance of Certification (MOC). So what do you have to do for “MOC”? In addition to having a license, most boards have requirements to document hospital privileges and provide letters of reference. Here’s a summary of the other requirements for four of the largest boards:

Being board certified is voluntary and so is maintaining a board. But, if doctors choose not to do MOC, they will lose their board certification.

Here’s some of the possible implications if a doctor loses board certification:

Hospital bylaws almost universally require staff members to be board certified. These bylaws will have to be rewritten for doctors who have lost their boards in order for them to work in these institutions.

Since the new MOC requirements went into place I have increased both the quantity and quality of the materials I use to stay up to date, which I strongly feel has made me a better surgeon. I still don’t like taking exams, but every time I do (I have three boards, so I take a lot of them!) I learn so much that I find the experience invaluable. (Yes, that’s after the exam, not before or during… that hasn’t changed since medical school.)

MOC isn’t perfect, but it’s evolving, and the reason it exists is a good one. Passing laws state by state to make MOC “optional” has the risk of hurting the public’s trust in physicians – and the risk of creating quite a bit of chaos for hospitals, training programs, and others. For what? Saving $200 a year? Not having to take the test every 10 years? Not having to log the CME that is required by almost all state medical boards?

“Here’s what’s at stake: we physicians are granted an extraordinary amount of autonomy by the public and the government. We ask people to disrobe in our presence; we prescribe medications that can kill; we perform procedures that would be labeled as assault if done by the non-credentialed. If we prove ourselves incapable of self-governance, we are violating this trust, and society will – and should – step into the breach with standards and regulations that will be more onerous, more politically driven, and less informed by science. That is the road we may be headed down. It is why this fight matters.” Robert Wachter, MD

I was delighted to be asked to be the AOA visiting professor at the University of Miami Miller School of Medicine this week. The following is the speech I gave at the induction banquet. For those who are not in medicine, Alpha Omega Alpha is the “Phi Beta Kappa” of medical school, an honor society that recognizes students who are at the top of their class… but who have also demonstrated service, leadership and professionalism.

What an honor that I have been asked to be here tonight for this celebration! I am in the company of superstars and great friends, both new and old … what could be better?

I want to start by congratulating the junior AOA, resident and faculty inductees. For the junior AOA inductees, you are clearly on a strong path to excellence which will serve you well. Although I’m going to address my remarks to the graduating seniors, please know that I haven’t forgotten you or what it took for you to be here tonight. For the resident and faculty inductees, you have been singled out for this very particular honor because you are amazing clinicians, educators and role models. Thank you for what you do.

I thought I’d start with a short description of what it means to be inducted into AOA from the AOA website.

“Election to Alpha Omega Alpha is an honor signifying a lasting commitment to scholarship, leadership, professionalism, and service. A lifelong honor, membership in the society confers recognition for a physician’s dedication to the profession and art of healing.”

Induction into AOA is a major milestone in your career and, based on your predecessors in the organization, it also represents the beginning of a remarkable journey. It’s a journey that you won’t take alone. If history is a guide, you represent the future leaders of medicine, which means you’ll be guiding others on this journey as well.

I suspect that you have all used a compass before but, like me, you probably haven’t given it much thought. A traditional compass works by aligning a needle to the magnetic pulls of the north and south poles. Although we really could use either north or south as a reference point, by convention we use north. I’m not going to get into the differences between true north and magnetic north*… suffice it to say that because a compass lets us know where north is, we can calculate the difference between “true north” and where we are heading, which in nautical terms, is called our “absolute bearing”.

So where am I going with this? Why is it important to have a point of reference, a “true north”, as you start your journey through residency into the practice of medicine?

I know you’ve already been on services where the focus seemed to be more on checking the boxes on the scut list than on caring for the patients… and you had the feeling that there was something missing.

That’s why you need a “true north”.

You’ve also been on committees or in organizations that seemed to worry more about policies and procedures than how to use those policies and procedures for the better good.

That’s why you need a “true north.”

And I know that you have experienced days where you manifested one or more of the three cardinal symptoms of burnout, days when you lost enthusiasm for your work, felt that patients were objects rather than people and/or decided everyone around you could do a better job than you could.

That’s why you need a “true north”.

Unless you know where your “true north” is, you can’t navigate… you can’t make the adjustments that keep you on course.

The single most important piece of advice I can give you as you start on this journey is to make sure you know where “true north” is for you. As each of you define your own personal “true north”, you will share things in common. For example, loving your family and friends, being kind, and trying to make a difference. But even though there will be common themes, “true north” will be a little different for each of you. This is not as abstract a concept as you might think. It is not only possible to articulate your goals, what gives you meaning and how you define your own integrity, it’s important to do so. And, yes, I mean write them down, think about them, and revise them when necessary. When you hit the inevitable days of stormy weather, having a compass that it true is critically important.

In reading about compasses, I also learned that the traditional compass has to be held level to work. I learned that “when the compass is held level, the needle turns until, after a few seconds to allow oscillation to die out, it settles into its equilibrium orientation.”

What a great image. You have to be still to let the compass equilibrate. You have to be mindful to look at the needle to calculate your absolute bearing. And then you have to take that information and apply it to correct your course. And to do so, you have to hold the compass level, which I think is a great metaphor for taking care of yourself – physically, emotionally and spiritually.

There is not a lot in the day to day life of an intern, resident or practicing physician that teaches us the skill of focusing on that still point, on getting our bearings to make sure we don’t veer off course.

It’s not a trivial problem. Veering off course can result in doing something we don’t want to do or, more importantly, becoming someone we don’t want to be. More importantly for those of you just starting on this journey, a small error in navigation at the beginning of a journey results in a very large error when you arrive. That’s why, as you start this journey, it’s so important to know what “true north” is for you.

As you articulate what your “true north” is, I would also urge you to translate it into something that is easy to remember for those times that you are making a decision in a difficult moment. For me, my “true north” as a physician has been distilled into three rules that I try to follow and that I teach my trainees.

Rule 1: Do what’s right for the patient.

Rule 2: Look cool doing it.

Rule 3: Don’t hurt anything that has a name.

Let me expand just a little…

Rule 1 means always do what’s right for the patient. Even if you are tired, even if others disagree, even if you don’t get paid, even if it’s not technically “your” patient – do what’s right. It also means developing an life-long method to deliberately read and study so you know the right thing to do. And it means doing all of this with compassion and integrity.

Rule 2, “Look cool doing it”, means practicing your art until you look cool. If you are surgeon, make sure your movements look like Tai Chi and that you have no wasted motion. If you are a pathologist, learn all the variations on the themes that cells can create. No matter what your specialty, read about each of your patients, prepare for all cases, procedures and conferences deliberately and diligently. “Look cool doing it” also means don’t lose your cool. Be professional, which at its core is just another way of saying kindness and integrity matter.

Rule 3, “Don’t hurt anything that has a name”, certainly means don’t cut the ureter if you are doing a colectomy, but it means more than that because…

You have a name.

Your significant other has a name.

Your institution, your friends, your family all have names.

You are about to embark on the amazing and challenging journey of residency… I know you have a sense of trepidation and also a sense of incredible excitement. Everyone in this room who has been there remembers and, to be honest, is probably a little jealous. What an amazing time to start a career in medicine.

Congratulations on all you have accomplished so far. I wish you smooth sailing and a compass that is true.

*Because I am using “true north” as a metaphor, the scientists will have to forgive me. There is a difference between “true north”, which is the actual north pole and “magnetic north” which is what a compass shows. Here’s a great link that explains this further: Magnetic North vs Geographic (True) North Pole

On the flight home yesterday I finished Big Magic: Creative Living Beyond Fear by Elizabeth Gilbert (She’s probably known to you for her NY Times Best Seller Eat, Pray, Love). For me, one of the overarching messages of her book was this – When you see what you do as your vocation (from Latin vocātiō, meaning “a call or summons”), and not just your job, it will transform how you view your work – a concept which I believe may be necessary (but not sufficient) to treat or prevent burnout.

As I read her thoughts on how to live a creative life, I realized that there were other ideas that applied to physicians, physicians in training and others who serve:

Just show up. Every day.

“Most of my writing life consists of nothing more than unglamorous, disciplined labor. I sit at my desk and I work like a farmer, and that’s how it gets done. Most of it is not fairy dust in the least”

Learning and practicing medicine (or any other field) means showing up – really showing up – every day. Everyone in the first year of medical school learns that it is different than college. Cramming for exams is not only ineffective, it’s just wrong. You are no longer studying for a grade on a test…. it’s now about the patients you will take care of in the future. The same holds true during residency and when you begin your practice. It’s not just when you are a trainee. Part of the “work” of medicine remains “unglamorous, disciplined labor”… keeping up with the literature, going to teaching conferences when you could be doing something else, finishing your hospital charts, being on call.

But the work of medicine is also about showing up every day in another sense, too – truly showing up for the people who rely on you – no matter what. That, too, can be “unglamorous, disciplined labor” when you are tired or stressed.

“Work with all your heart, because—I promise—if you show up for your work day after day after day after day, you just might get lucky enough some random morning to burst right into bloom.”

“They are your patients… from the first day of medical school until you retire.

“Most of all, there is this truth: No matter how great your teachers may be, and no matter how esteemed your academy’s reputation, eventually you will have to do the work by yourself. Eventually, the teachers won’t be there anymore. The walls of the school will fall away, and you’ll be on your own. The hours that you will then put into practice, study, auditions, and creation will be entirely up to you. The sooner and more passionately you get married to this idea—that it is ultimately entirely up to you—the better off you’ll be.”

Caring for others gives us joy but also gives us the responsibility to know the best thing to do for them. Whether you are a first year student, 3rd year resident or a PGY35 attending, we are all still learning. “Life long learning” is not just a phrase, it’s the reality of what we do.

“It’s a simple and generous rule of life that whatever you practice, you will improve at.”

Learn the art of deliberate practice early. Deliberate practice, to use a musical analogy I learned in Cal Newton’s fantastic book So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love, doesn’t mean playing the piece from start to finish 20 times in an hour. It means spending 55 minutes on the small section that you struggle with, repeating it 100 times before you play the piece through once. It means instead of reading the comfortable material on the anatomy of the kidney, you deliberately tackle how the nephron works. It means that instead of doing the computer-simulated cholecystectomy 10 times you spend an hour tying intracorporeal knots in the trainer. Find the thing that is not easy and practice it over and over until it becomes easy.

“There are only so many hours in a day, after all. There are only so many days in a year, only so many years in a life. You do what you can do, as competently as possible within a reasonable time frame, and then you let it go.”

One of the greatest attributes of those who care for others is their devotion to the people they serve. But perfectionism, taken to its extreme, is dangerous. Extending your time to study for Step 1 beyond what is reasonable to try to get a higher score, revisiting decisions about patient care to the point of anxiety, worrying that your GPA has to be perfect are all counterproductive. The motivation to do well is like a cardiac sarcomere – a little worry will make you more effective, but stretched too far, there won’t be any output at all.

“No, when I refer to “creative living,” I am speaking more broadly. I’m talking about living a life that is driven more strongly by curiosity than by fear.”

It’s something most students don’t realize, but no matter how long you practice medicine, there are days when you are afraid. It takes courage to do what we do. Remember, being courageous is not an absence of fear, it’s being able to do what’s right despite the fear. I agree complete with Elizabeth Gilbert that curiosity helps. When you have something that doesn’t go the way you expect or frightens you, instead of beating yourself up (“I should have studied more”….”I could have made a different decision”…etc…etc) become curious. If you are thinking about a complication, commit to finding everything you can about the procedure and how to prevent complications. If you didn’t do as well on your test as you thought you should, look up different techniques to study, take notes, and remember information, and go back to make sure you really understood what was being tested.

Even more powerful than curiosity is gratitude. Fear and gratitude cannot exist at the same moment. Try it – the next time you are about to snap because your EMR freezes be grateful that you can see the computer, be grateful you have work, be grateful you have been trained to help other human beings …and see what happens.

“We must have the stubbornness to accept our gladness in the ruthless furnace of this world.”

“You can measure your worth by your dedication to your path, not by your successes or failures.”

Wow…. This one is so important.

It’s not what you make on Step 1. It’s not how many cases you do, how many patients you see or how much money you make. This concept is taught by every religion and philosopher I know – for a reason. Be devoted to doing the best you can and to forgiving yourself (and learning from it) when you fall short.

Find something, even a little tiny thing, that makes you curious (or fills you with wonder) and follow it. Dedicate yourself to following that curiosity and it will likely lead you to your career.

“May I also urge you to forget about passion? Perhaps you are surprised to hear this from me, but I am somewhat against passion. Or at least, I am against the preaching of passion. I don’t believe in telling people, “All you need to do is to follow your passion, and everything will be fine.” I think this can be an unhelpful and even cruel suggestion at times. First of all, it can be an unnecessary piece of advice, because if someone has a clear passion, odds are they’re already following it and they don’t need anyone to tell them to pursue it…..I believe that curiosity is the secret. Curiosity is the truth and the way of creative living. Curiosity is the alpha and the omega, the beginning and the end. Furthermore, curiosity is accessible to everyone…..In fact, curiosity only ever asks one simple question: “Is there anything you’re interested in?” Anything? Even a tiny bit? No matter how mundane or small?….But in that moment, if you can pause and identify even one tiny speck of interest in something, then curiosity will ask you to turn your head a quarter of an inch and look at the thing a wee bit closer. Do it. It’s a clue. It might seem like nothing, but it’s a clue. Follow that clue. Trust it. See where curiosity will lead you next. Then follow the next clue, and the next, and the next. Remember, it doesn’t have to be a voice in the desert; it’s just a harmless little scavenger hunt. Following that scavenger hunt of curiosity can lead you to amazing, unexpected places. It may even eventually lead you to your passion—albeit through a strange, untraceable passageway of back alleys, underground caves, and secret doors.

“Email is both a miracle and a curse. At no other time in human history have we been able to exchange messages instantly globally; but at the same time, our ancestors didn’t spend hours each day sifting through memos, missives and newsletters we probably should just unsubscribe from.” Kadhim Shubber

In the last few weeks, I have spent time counseling colleagues who had real issues after missing one or more critical emails. I totally understand why… the volume of emails, and particularly of spam we all get is totally out of control. But the volume doesn’t really matter when you miss a critical deadline or, in the case of some medical students this year, an offer for a residency interview.

The key is to have a system – and to change the way you look at email.

When you open an email message you only have three options and one of them is not to keep it in your inbox! Don’t use your inbox as a “to do” list – the emails will stack up and it becomes unmanageable. The simple way to avoid this is to open each email message and immediately do one of three things:

Delete it

Answer it

Create a task

Other important things to know about deleting (or not deleting)

Microsoft has recently introduced a new function for Outlook called Clutter. It’s a good thing – as long as you know it is there and how it works! In a nutshell, this function uses your behavior to decide if you want to see the email or if the email should automatically be sent to the “clutter” folder. Beware – you need to either check the folder or disable this function, particularly at first.

Create a task? I am a big fan of Remember the Milk, but there are many other “to do” programs out there that would work, too. When I get an email that I need to turn into a task I send it to the “inbox” of my Remember The Milk account. Once it’s there, you then

Put it in a list (the four lists in my account are “Today”, “This week”, “Projects” and “Ideas”, but you can create any lists you want)

Give it a priority

Give it a due date

Set a reminder (if you need to)

Check your list! However you choose to make your task list, check it every evening to organize the next day’s tasks. This is critical to making this work. Don’t list 20 things either. Be realistic and put the top 3-5 things on this list!

Check your email! Check your email at least once a day, but not all the time… and NOT at your most mentally active time! For most people that means checking email in the afternoon or evening.

Change your mindset. Email is how professionals communicate, so we all have to learn how to handle our inbox without becoming frustrated or angry.

I learned a very valuable approach from a friend one day when we were talking about email. I said there were times I just dreaded sitting down … and even got angry because of the volume of emails I have to answer. Her solution? Turn answering email into an exercise of gratitude. Be grateful that you have hands to type, eyes to see the screen, and the privilege of work.. As simple and potentially silly as this seems, it is a powerful tool to change how you look at answering emails. (p.s. it also works for the EMR!)

Around the world, Ebola and other infectious diseases take the lives of mothers, fathers, sons and daughters … and place at risk those who care for them. This risk is known to all who choose medicine as their career. It is part of caring for the ill, and always has been.

“A healthcare provider has an ethical and professional duty to address a patient’s needs, as long as the patient’s diagnosis – or when the patient’s initial complaint, on the face of it – falls within the provider’s scope of practice.Refusing to do so is not consistent with the ethical principle of beneficence. “ Twardowski, et. al. RI Med Jl October, 2014

Around the world, physicians, nurses, and all healthcare workers willingly fulfill their duty to care for patients who are or might be ill with Ebola and other dangerous diseases, reflecting the altruism and compassion of those who choose medicine for their career.

However, the duty to care for these patients does not automatically extend to those who are learning medicine. Without the experience, context and well developed skills of established providers, trainees are potentially at greater personal risk.

When I operate on patients with HIV, Hepatitis, or any blood-borne pathogen, I take every precaution possible for myself and the staff who are scrubbed. I also take advantage of the “teachable moment” to discuss ethics and universal precautions with my trainees…. but I don’t allow medical students or junior residents to directly participate in the case. Likewise, I am sure that learners will not be allowed to provide direct care for patients known to be infected with Ebola or other dangerous diseases… or to travel to West Africa for clinical experiences while the epidemic is still present.

All of us in medicine honor those who provide care to the ill despite the risk …and we thank you for the example you are setting for those learning to heal. We hold our colleagues in Dallas, Atlanta, Africa and around the world in our thoughts as they work tirelessly to heal the sick and contain this terrible disease.

It’s not often that a talk completely changes the way I think about something.

I’ve been thinking and speaking about compassion fatigue for many years. I recently had the privilege of hearing a wonderful talk by Roshi Joan Halifax. She made a strong and convincing case that “compassion fatigue” is a misnomer… and that we should think about this in a very different way.

We can never have too much compassion nor can true compassion result in fatigue.

Empathy is a necessary prerequisite for compassion, but compassion goes beyond empathy. Empathy is the ability to be with someone who is suffering, to be able to feel what they are feeling. Compassion, on the other hand, is being for someone who is suffering, being moved to act and find a way to relieve their suffering.

Self-regulation is the key to being able to remain compassionate and this skill can be taught.

We all respond to situations of suffering with “arousal”, a state that varies in intensity depending on the severity of the suffering, and our own memories and experiences. How you respond to this state determines whether you can stay present, effective and compassionate. Roshi Joan Halifax offered the mnemonic “GRACE” as a way to teach this skill to medical students, residents, physicians, nurses and other health care professionals.

G: Gather your attention. Take three deep breaths. Be present.

R: Recall your intention. We choose careers in medicine to help heal the sick and to reduce suffering. It’s not easy to remember this intention when we are overwhelmed. But, in the moment we are faced with a human being who is suffering, we must let our own response (and the demands of the day) go and remember why we are here.

A: Attend to yourself. Being able to detect what is going on in your own body is the same “wiring” you use when you feel empathy. After gathering your attention and recalling your intention, pay attention to what is going on in your body. Watch your breath, feel where there is tension, pay attention to sensations.

C: Consider what will really serve. Moving from empathy to compassion is defined by considering the actions that will relieve suffering. Really consider the person and the situation and decide what is most likely to improve the situation.

E: Engage ethically.

“Developing our capacity for compassion makes it possible for us to help others in a more skillful and effective way. And compassion helps us as well.” Joan Halifax

The following is the 2012 First Prize winning essay in the Arnold P. Gold Foundation Annual Essay Contest, written by Carmelle Tsai, a Baylor College of Medicine student. It’s my pleasure to share it with you – and congratulations to Carmelle!

There is nothing normal about being a physician, or training to become one.

On the second day of medical school, I cut open a dead man’s body. Soon thereafter, I found myself in the lab many times over, pulling various body parts out of drawers and staring at them for hours. Alone. Sometimes until midnight.

I have stood in a trauma operating room, wearing a gown splattered with a dying person’s blood. I have seen, heard, and smelled things I never thought could come from the human body. I have stuck tubes and needles into other people’s flesh. I have put a gloved finger into someone else’s rectum more times than I care to count.

It’s just. Not. Normal.

It’s horrendous, grotesque—plain weird, some of the stuff we do. But it’s all in the noble name of medicine, of saving lives, of healing. I know that. We all know that. We even think it sounds heroic. So to soften the somewhat uncouthly nature of what we do, we give procedures benign names and talk about them gently, as if doing so could somehow preserve the dignity of the human beings involved. We kindly write on the chart “Below the Knee Amputation,” and we gently explain that we will be doing a “simple procedure” to remove your cyst.

And yet once in a while, I just want to scream: “It’s NOT OKAY! It’s NOT NORMAL! There is NOTHING NORMAL about using SAWING OFF a poor old woman’s leg!!!” It’s like something inside of me cries out just for us to call it what it is, and to quit tiptoeing around, pretending that what we do is dignified.

Before I entered medicine, I always knew I wanted to heal my patients compassionately by listening, holding their hands, and being present with them. But what I did not understand was how I would learn to steward medicine by healing patients and myself through some less-than-likely moments.

I was wheeling Mrs. N into the operating room. She was a sweet, middle-aged woman with a husband and three kids. The anesthesiology team and I worked together to be compassionate and kind as we prepped her for surgery.

Though things were chaotic the moment we burst into the OR and were greeted by a barrage of shiny machines and people, we all set swiftly into motion. As we did, we paid attention to Mrs. N’s comfort as best we could. My resident smiled as he told her about his own kids. The nurses thoughtfully brought her a pillow. I held her hand as the arterial line was being placed.

“Y’all are so sweet,” she said with a tinge of Southern drawl.

I smiled at her through my surgical mask as I gave her oxygen. Soon, Mrs. N was asleep. As the resident began to place her central line, I walked around the monitors, tucked in her blanket, and adjusted the sock on her left foot that had gotten twisted around in the pre-surgery shuffle.

As I gave her foot a reassuring pat, I caught myself thinking, “What? You’re ridiculous, Carmelle. She’s asleep. She can’t tell that it’s cold and she’s not awake to be annoyed that her sock is on funny.” For a moment I felt foolish. I mean, really?

My resident looked at me and raised an eyebrow. I shrugged.

In a few moments, a surgeon would be cracking open Mrs. N’s chest. Then we would put her heart on bypass. Then her entire aortic valve would be replaced. A turned-around sock hardly seemed like a big deal. Plus, the groggy and awful dry-heaving that would precede her extubation, and the pain from having her insides all cut, moved around, and put back together would surely distract her from the ugly yellow hospital socks. And I was right. Later when I saw Mrs. N post-op, I wasn’t even sure if she was wearing socks.

I pondered about Mrs. N and her socks on the way home that day. It reminded me of my first day of anatomy. Before we were about to unzip the bag and remove our cadaver, I made all my teammates stop and just breathe for a moment. I wasn’t really sure why—again, what does it matter, right? The man was already dead and his body had been in formaldehyde for months.

But I realized it did matter. I understand now that my humanity is why I do these things. It is not for the dead man, for Mrs. N, or for anyone else. It is for me. And because it matters to me, in some roundabout way, it matters to Mrs. N, and to all my patients. Because in medicine I am meant not only to heal, but to be healed.

And that, I have found, is what it truly means be a steward. It is to invest in my patients by being humbled enough to recognize that they offer me something too. As much as medicine gives physical healing, and the holding of hands and compassionate silence give emotional healing, it is part of my own healing to maintain that same humanity in the moments that patients neither see nor experience.

I am not any less broken just because I know more about the human body. Just because my normal involves everything that most people think is crazy or disgusting does not mean that I am any different. I also don’t like being cold. I don’t like wearing my socks backwards. I am scared of foreign situations. I am in need of healing.

And so if reminding myself that what seems cruel and abnormal is still compassionate means that I will kindly refer to sawing someone’s leg off as a “below the knee amputation” or tuck in the blankets on a sleeping patient, damn right I’m going to do it. There is no way we can steward medicine if we cannot allow ourselves to be healed, too. Yellow hospital socks and all.

I was asked to speak at the monthly Texas Children’s Hospital Department of Surgery fellows’ conference this week. The surgery fellows at TCH have finished their training in Anesthesiology, Cardiac Surgery, General Surgery, Gynecology, Plastic Surgery, Ophthalmology, Orthopedic Surgery, Otolaryngology, Neurosurgery or Urology, and are now doing one to two more years specializing in the care of children. At a minimum, they are in their 5th or 6th year of postgraduate training. Because of the length of some of the programs (and extra research experience) some of them are in their 9th or 10th year of postgraduate training. They are an amazing group of surgeons at an exciting time in their careers. Picking a topic wasn’t easy.

After thinking about it, I decided to put together a talk on the 10 things I wish someone had told me before I started my first job as an attending. There are potentially more, but here is what I came up with as a place to start:

Your idea of “success” will change during your career.

Time management starts with knowing what’s coming

Pay yourself first

Learn from every patient

Join and be active in professional organizations

Meet regularly with (many) mentors

Be positive

Do what’s right for the patient.

Look cool doing it.

Don’t hurt anything that has a name.

As we discussed these topics, I realized that some of these ideas would also be of interest to medical students, other residents and physicians early in their practice. So, I’ve decided to take these on as a series of posts. More to follow!